Question

What are four risk areas identified for physicians in the Officer of Inspector General’s (OIG) Compliance Program Guidance for Individual and Small Group Practices.

Answer 1

Answer: Compliance Program Guidance

1. Identification of vulnerabilities

The Office of Inspector General (OIG) has identified coding and billing, reasonable and necessary services, documentation, and improper inducements as potential risk areas affecting physician practices.

Based on this guidance, begin with the following when evaluating risk areas in your practice:

• Data entry accuracy
• Encounter form vs. billing record
• Explanation of benefits (EOBs)
• Denials
• Secondary insurance submission
• Patient statements
• Sufficient documentation to validate medical necessity (for billing, as opposed to clinical, purposes)
• Legible identity of the provider
• Legibility
• Identification of patient
• Date of service
• Place of service (POS)
• Chief complaint/reason for encounter
• Cloning/copy and pasting
• Documentation of tests, procedures, etc., in the record
• Documentation of time-based codes
• Incident-to compliance review
• Improper use of modifiers
• HIPAA security and privacy.

2.Benchmark:

Benchmark your data to determine if any of your providers are outliers (i.e., their billing patterns are markedly unlike those of their peers), which could cause them to become targets for an audit. If Medicare identifies a provider as an outlier, it is not a foregone conclusion the provider is submitting inappropriate claims; however, when a practice identifies a provider as an outlier, it is prudent to verify the billed services are accurately and appropriately documented and coded.

3.Assesing the risk:

When a vulnerability or risk has been identified, it is important to determine the risk rating. Using a risk matrix similar to the one pictured, below, a risk rating will be assigned to each potential risk.